Duke-Margolis is researching payment and delivery reform models being implemented outside of the United States that are applying the principles of accountable care. We have conducted this analysis in parallel with a project supported by the Commonwealth Fund.
Recently, Dr. Mark McClellan chaired the Accountable Care Forum for the 2016 World Innovation Summit for Health (WISH), a bi-annual health policy summit held in Doha, Qatar and global community of health policy researchers. Building on prior work led by Dr. McClellan in 2013 and 2015, this year’s forum explored a policy agenda to help policymakers adopt accountable care to support transformative steps and innovations in their own countries.
The research team worked with an advisory group comprised of international health policy, payment and provider leaders to expand the ‘accountable care framework’ to include internal (organizational capabilities) and external (policy context) factors that matter when policymakers begin to implement reforms that move toward value-based approaches. Earlier this year, the framework was showcased at a Health Affairs briefing in Washington, D.C. We systematically applied this framework to case studies from diverse economic, geographic and health policy settings to illustrate how accountable care’s explicit focus on achieving better outcomes for a population – backed by a commitment to measure and support progress – can enable patient-centered innovations in care. Dr. McClellan presented the final report at WISH 2016 on November 29-30, 2016 in Doha, Qatar.
This report was written by Dr. McClellan in collaboration with Andrea Thoumi of the Margolis Center for Health Policy at Duke University; Dr Krishna Udayakumar of Innovations in Healthcare and the Duke Global Health institute at Duke University; Hannah Patel of Imperial College London; and Professor Abdul Badi Abou Samra of Hamad Medical Corporation. Kushal Kadakia and Jonathan Gonzalez-Smith of the Margolis Center for Health Policy at Duke University provided research support.
Most countries have well-established mechanisms to pay for medical treatments. However, many innovations – telemedicine, use of community health workers and lower-cost versions of treatments – are inadequately reimbursed, if reimbursed at all. Payment systems are often slow to support new care models, and understandably so: additional payments for innovations create fiscal concerns; innovations may not be cost-effective unless integrated appropriately with other services; and existing institutions may lack experience or clear authority to support new services. Accountable care can help to overcome such barriers.
Accountable care seeks to align health financing and regulatory systems with person-centered care reforms and enable changing population health needs and opportunities to be addressed at a lower cost. We define accountable care as a group of providers who are held jointly accountable for achieving a set of outcomes for a defined population over a period of time and for an agreed cost. Evidence suggests that adopting accountable care through incremental policy changes or comprehensive payment reforms can reduce hospital re-admissions, emergency department use and overall spending. Accountable care can also increase patient satisfaction, improve chronic disease management and prevent costly complications.
To implement accountable care requires new organizational capabilities and professional expectations. Effective implementation is not only technical. It will involve putting into practice new performance measures and financing models, but also steps to support healthcare organizations in managing change.
The report identifies four key early steps for policymakers to take:
- Shifting to a patient- not provider-focused accountable care regulatory infrastructure. To drive patient-focused healthcare policies, policymakers can adopt standard performance measures; invest in secure data sharing capabilities; identify specific high-priority opportunities; support workforce regulations; overcome institutional silos; and create cross-cutting mechanisms that have real authority.
- Supporting the development of healthcare organizational capabilities. Policymakers can help organizations shift toward a patient or population approach by establishing peer learning networks to exchange lessons learned; invest in developing the leaders with new skills; and establish pathways for growth. Upfront investment to implement innovations and transform care also helps.
- Aligning financial and non-financial supports to change provider and population behavior. Aligning the right financial and non-financial supports to change behavior while providing sufficient funding to innovate has been difficult. Policymakers can advocate for financing reforms that enable more flexible support for providers to implement care innovations, and ensure that the innovations are targeted at patients who truly benefit.
- Collaborating with providers, population groups and other stakeholders. While accountable care can benefit from global experiences and best practice, engagement and joint development of the specific features of accountable care across interest groups is a key element to success. Policymakers should explore ways to include providers and the population in the policy development process to help build trust around new policies and to ensure that they will succeed in local conditions.
The Case Studies
Case studies from diverse economic, geographic and health policy settings illustrate how accountable care’s explicit focus on achieving better outcomes can enable patient-centered healthcare innovations, backed by a commitment to measure and support progress. We highlight three approaches, illustrated through case studies in the report:
- Innovative primary care-focused reforms to build efficient access to low-cost preventive and primary care services and better co-ordination with advanced and specialized care. Examples include Healthspring in India, Possible in Nepal and One Family Health in Rwanda.
- Problem-focused care reforms to support broader access to more efficient, high-quality services for ‘episodes’ of care for specific conditions. Examples include CASALUD in Mexico and the SMART Diabetes Pilot in Qatar.
- Comprehensive care reforms to incorporate accountability for the full spectrum of care for a population. Examples include Gesundes Kinzigtal in Germany, the Better Together Programme at Mid Nottinghamshire Vanguard in the United Kingdom and Rio Grande Valley Accountable Care Organization (RGV ACO) in the United States.
Mark McClellan, MD, PhD
Andrea Thoumi, MSc, MPP
Krishna Udayakumar, MD, MBA
Founding Faculty, Duke-Margolis
Associate Professor of the Practice of Global Health, Duke Global Health Institute
Associate Professor - Track IV in Medicine, General Internal Medicine
Jonathan Gonzalez-Smith, MPAff
Senior Research Assistant
Undergraduate Research Assistant
Mary Ackenhusen, President and CEO, Vancouver Coastal Health, Canada
Dr Salih Ali Al-Marri, General Secretary Assistant for Health Affairs, Ministry of Public Health, Qatar
Flora Asuncion, Assistant Managing Director, Primary Health Care Corporation, Qatar
Jason Cheah, CEO, Agency for Integrated Care, Singapore
Santiago Delgado, Corporate Development Officer, Ribera Salud, Spain
Jennifer Dixon, CEO, Health Foundation, UK
Michael Macdonnell, Director of Strategy, NHS England, UK
Akiko Maeda, Lead Health Specialist, HNP Global Practice, World Bank, US
Pradeep Philip, CEO, LaunchVic, Australia
Steve Shortell, Blue Cross of California Distinguished Professor of Health Policy and Management, University of California-Berkeley, US
Lawrence Tallon, Managing Director, The Shelford Group, UK (formerly Executive Director, Hamad Medical Corporation, Qatar)
Gavin Yamey, Professor of the Practice of Global Health, Duke University, US
Funding for this project is provided by the Qatar Foundation.